Diary from a Week in Practice

Am Fam Physician. 2000 Dec 1;62(11):2429-2430.

Monday

WLL practices in the office only part time now. Outside of the office, he applies his medical knowledge in the television and radio arenas. Because of his travel schedule, it has been difficult to remain apace with the practice. After several heart-to-heart discussions, our group and WLL reached a consensus that he would best serve the practice and his patients working in the outpatient and medical media worlds and allowing our practice to provide care to his patients needing hospitalization. Arguably, WLL has been one of the foremost family medicine spokespersons for maternity care in the country over the past 15 years. This past December, WLL attended the last of more than 1,500 births he has attended over a quarter of a century. The mom was one of our infertility patients who finally became pregnant at 40 years of age. The labor was long and the delivery difficult, but mom, dad and baby all did well. After the birth, WLL lingered a bit longer than was his habit. Many memories flooded back as he savored the past 25 years of experiences attending births.

Tuesday

In the June 1, 2000, entry of “Diary,” we shared a letter mentioning Duke's Magic Mouthwash. Several readers have since requested the recipe. It was developed at Duke University and is used for aphthous ulcers. The recipe mixes nystatin suspension, 100,000 U per mL, 30 mL or nystatin powder 3 million units, 60 mg hydrocortisone and diphenhydramine HCL syrup to a sufficient quantity 240 mL. Ten mL is swished and swallowed four times a day for five to 10 days. JTL has prescribed Duke's Magic Mouthwash with generally favorable results. While many of these remedies use viscous lidocaine or diphenhydramine as their base, JTL has been intrigued by the variety of “additives,” which seem to confer medicinal properties. JTL has found this concoction to be easy for pharmacists to prepare and agreeable to patients: 120 mL viscous lidocaine; 40 mL erythromycin (400 mg per 5 mL); 40 mL methylprednisolone elixir (15 mg per 5 mL). He instructs patients to gargle and swallow or spit out (depending on location of the lesions) 5 to 10 mL at least five times daily until lesions resolve. While this concoction works nicely for sores located in the oropharynx, lesions located around the lips and gums may benefit from a combination of topical corticosteroid gel (e.g., fluocinonide) and an oral antiviral remedy such as acyclovir, as noted in a published report (J Inf Dis June 2000;181:1906–10).

Wednesday

Many patients find that the so-called effective herbal therapies are not all that helpful. In May 2000, Consumer Reports published a survey of nearly 47,000 readers. A high percent of respondents had some, little or no relief from a number of herbal products that have been shown in medical studies to be helpful. For example, the percentage reporting they had some, little or no help with various disorders included 82 percent using garlic for high cholesterol, 75 percent using echinacea for colds or influenza, 82 percent using melatonin for sleep, 76 percent using glucosamine for arthritis, 76 percent using St. John's wort for depression and 76 percent using saw palmetto for prostate problems. The most likely explanation is poor product quality. Herbal products are unregulated in the United States, and many manufacturers do not control for quality. The survey studied a number of ginseng products and found little correlation between the quantity of ginseng listed on the label and the quantity of ginsenoside (believed to be the active ingredient). An even bigger problem was that capsules with the largest amounts of ginsenoside were not labeled as having more ginseng.

Thursday

In a past “Diary” entry, WLL wrote about his grandfather's teaching and our practice's application of the “Philosophy of Apology.” However, a proper and appropriate apology and the acknowledgment of medical mistakes still seem to be rarely taught in medical education. Furthermore, insurers, malpractice attorneys and risk managers have historically advised doctors to keep quiet after a bad outcome. This is probably in fear of malpractice and the risk of embarrassment. Legal changes in some states may make it easier for physicians to apologize for an unintended outcome without fear of it being used against them in court. Legislatures (and courts in some jurisdictions) are beginning to protect apologies and other “benevolent gestures”(such as expressing sympathy) from being admitted as evidence of liability in medical malpractice and other accident cases. California and Texas have enacted such laws this year that were modeled after a similar law in Massachusetts. Legislation is currently being drafted in Florida and Virginia. In addition, according to the American Medical Association, the high courts in Vermont and Georgia have upheld protections for apologies. Doing what is right should not require a law; however, once these laws are in place, they may allow family physicians to do what they know is right, even if they did not previously have the courage to do so.

Friday

“Your next patient has a rash. I escorted him out of the waiting room and put him in an examination room for you.” With this short history from her nurse, ASW approached the examination room to do one of her favorite things—evaluate an unusual rash. She walked in to find a young man pacing the room while vigorously scratching his torso. Without a chance to speak, ASW was asked to look at this rash and relieve the unbearable itching. She asked the irritated patient to remove his shirt and attentively examined the “rash” on his chest; she was shocked to realize that he was pointing at freckles. Puzzled and confused, ASW asked for further history. The patient then proceeded to carefully pick a piece of lint off his black shirt, give it to ASW and say “Go look at this under the microscope and see what it is. I've had bugs crawling on me for hours and it's driving me nuts.” As she began catching on to this interesting presentation, she politely took the “bug,” called in a nurse to “assist the patient” (to ensure that he didn't hurt himself or someone else), and ordered a urine drug screen. Within minutes, the mystery of the invisible bug and subsequent “rash” was unraveled: his screen was positive for cocaine and he was admitted for treatment. Without a doubt, this was the most interesting presentation of a “rash” ASW has ever seen.

Saturday/Sunday

“Anxiety is overwhelming for a seven-year-old.” That was the message JTL received on his pager this Sunday afternoon. Responding to the page, JTL listened to the mother of a seven-year-old boy explain that she and her son had recently made a trip to California to visit her dying uncle. Since the visit, her son had become very anxious and spoke frequently of dying. When her uncle died a few days earlier, the mother decided to have her son stay with a friend while she returned to California. On her return two days later, her son, utterly distraught and uncontrollable, asked his mother to take him to the doctor so he could feel better. Visiting with him over the telephone, JTL was able to get the child to stop crying and let him know that he would try to help. JTL suggested that the mother take her son to a restaurant where he would get a good meal and find some children to play with. (JTL has noted that sad children rarely remain sad once they get around other children at play.) While this suggestion and some words with the boy seemed to help at least temporarily, JTL realized that the traumatic experience of “losing” his mother (if only for two days) might require further therapy, so he suggested to the mother that she make an appointment.

This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Amaryllis Sanchez Wohlever, M.D., and John T. Littell, M.D., four family physicians in private practice in Kissimmee, Fla.


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